Differences in the prescribing of medication for physical disorders in individuals with v. without mental illness: meta-analysis.

BACKGROUND: There is some concern that patients with mental illness may be in receipt of inferior medical care, including prescribed medication for medical conditions. AIMS: We aimed to quantify possible differences in the prescription of medication for medical conditions in those with v. without mental illness. METHOD: Systematic review and random effects meta-analysis with a minimum of three independent studies to warrant pooling by drug class. RESULTS: We found 61 comparative analyses (from 23 publications) relating to the prescription of 12 classes of medication for cardiovascular health, diabetes, cancer, arthritis, osteoporosis and HIV in a total sample of 1 931 509 people. In those with severe mental illness the adjusted odds ratio (OR) for an equitable prescription was 0.74 (95% CI 0.63-0.86), with lower than expected prescriptions for angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARBs), beta-blockers and statins. People with affective disorder had an odds ratio of 0.75 (95% CI 0.55-1.02) but this was not significant. Individuals with a history of other (miscellaneous) mental illness had an odds ratio of 0.95 (95% CI 0.92-0.98) of comparable medication with lower receipt of ACE/ARBs but not highly active antiretroviral therapy (HAART) medication. Results were significant in both adjusted and unadjusted analyses. CONCLUSIONS: Individuals with severe mental illness (including schizophrenia) appear to be prescribed significantly lower quantities of several common medications for medical disorders, largely for cardiovascular indications, although further work is required to clarify to what extent this is because of prescriber intent.

Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies.

BACKGROUND: There has been long-standing concern about the quality of medical care offered to people with mental illness. AIMS: To investigate whether the quality of medical care received by people with mental health conditions, including substance misuse, differs from the care received by people who have no comparable mental disorder. METHOD: A systematic review of studies that examined the quality of medical care in those with and without mental illness was conducted using robust critical appraisal techniques. RESULTS: Of 31 valid studies, 27 examined receipt of medical care in those with and without mental illness and 10 examined medical care in those with and without substance use disorder (or dual diagnosis). Nineteen of 27 and 10 of 10, respectively, suggested inferior quality of care in at least one domain. Twelve studies found no appreciable differences in care or failed to detect a difference in at least one key area. Several studies showed an increase in healthcare utilisation but without any increase in quality. Three studies found superior care for individuals with mental illness in specific subdomains. There was inadequate information concerning patient satisfaction and structural differences in healthcare delivery. There was also inadequate separation of delivery of care from uptake in care on which to base causal explanations. CONCLUSIONS: Despite similar or more frequent medical contacts, there are often disparities in the physical healthcare delivered to those with psychiatric illness although the magnitude of this effect varies considerably.

Community mental health teams for people with severe mental illnesses and disordered personality.

BACKGROUND: Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favor of providing care in a variety of nonhospital settings, underpins the rationale behind care in the community. A major thrust toward community care has been the development of community mental health teams.

Physical health and schizophrenia.

PURPOSE OF REVIEW: Patients with schizophrenia have higher than expected rates of morbidity and mortality. It is debatable whether this is related to shared risk factors, antipsychotic medication or inherent to the condition itself. This review will describe this association and the recent advances in the field. RECENT FINDINGS: The majority of patients with schizophrenia have at least one chronic comorbid medical condition. In the absence of systematic screening this may or may not be brought to the attention of health professionals. The cause of high rates of physical illness appears to be multifactorial involving shared vulnerability and genetic factors. Yet it is vascular risk factors and the adverse effects of prescribed medication that are most amenable to intervention. Current atypical antipsychotics may offer neurological and cognitive benefits, but there is accumulating evidence of problems with weight gain, diabetes, lipid dysregulation, metabolic syndrome and sexual side effects. SUMMARY: The physical health of patients with schizophrenia remains a concern. Yet the quality of medical and psychiatric care of patients with comorbid physical and mental health disorders has been shown to be unsatisfactory in several areas. We suggest that clinicians routinely assess and monitor physical health needs of patients with serious mental illness.

Epidemiology of child homicide in Jefferson County, Alabama.

OBJECTIVE: The purpose of this study was to present the epidemiology of homicide among children younger than 6 years of age in Jefferson County, Alabama. This study focused on obtaining great detail on homicides and suspicious deaths occurring within a fixed population. METHODS: For purposes of this study, cases included Jefferson County deaths attributed to "homicide" or that were "undetermined" as noted in the coroner files among children younger than 6 years of age who were born and died between January 1, 1988 and December, 31, 1998. Victim and offender characteristics were obtained from the Jefferson County Coroner/Medical Examiner Office records. Environmental factors and circumstances surrounding the death were noted as well. RESULTS: The 53 study subjects were mainly female (55%), Black (69%), younger than 2 years of age (85%), had single mothers (38%), and a history of abuse (53%). Offenders were more likely to be male (64%), Black (73%), and a parent of the victim (53%). Homicides primarily resulted from an angry impulse (61%), with hands the most common weapon (61%). CONCLUSIONS: The majority of deaths in this study occurred among children younger than age 2, with a high proportion of fatalities among Black children of unmarried mothers. The offender most often knew the victim, with half of all homicides and two-thirds of all infant homicides involving a parent. More than half of the homicides resulted from an angry impulse, while the most common scenario for deaths with undetermined intent involved the caretaker finding the child unresponsive.

Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis.

BACKGROUND: There has been long-standing concern about the delivery of preventive and screening services to patients with mental illness. OBJECTIVE: We aimed to examine whether the quality of preventive care received by patients with mental health conditions differs from that received by individuals who have no comparable mental disorder. Our hypothesis was that patients with mental illness would be in receipt of lower quality or lower frequency of preventive care. METHOD: Studies that examined the quality of care in those with and without comorbid mental illness were reviewed and comparative data extracted. By using only comparative studies we hope to ascertain whether inequalities in care existed by virtue of psychiatric diagnoses (or closely affiliated factors). RESULTS: We identified 26 studies that examined preventive care in individuals with vs. without psychiatric illness. From these eligible studies, 61 comparisons were documented across 13 health care domains. These included mammography, cervical smears, vaccinations, cholesterol screening, lifestyle counseling, colonoscopy. Twenty-seven comparisons revealed inferior preventive health care in those with mental illness, but 10 suggested superior preventive health care and 24 reached inconclusive findings. Inferior preventive care was most apparent in those with schizophrenia and in relation to osteoporosis screening, blood pressure monitoring, vaccinations, mammography and cholesterol monitoring. CONCLUSIONS: We conclude there is strong evidence to suggest that the quality of preventive and screening services received by patients with mental illness is often lower, but occasionally superior to that received by individuals who have no comparable mental disorder. More work must be done to improve the quality of medical and preventive care for individuals with mental illness.

Panic disorder.

INTRODUCTION: Panic disorder occurs in up to 3% of the adult population at some time, and is associated with other psychiatric and personality disorders, and with drug and alcohol abuse. The risk of suicide and attempted suicide has been found to be higher in people with panic disorder than in people with other psychiatric illness, including depression. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-drug treatments for panic disorder? What are the effects of drug treatments for panic disorder? What are the effects of combined drug and psychological treatments for panic disorder? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 36 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: applied relaxation, benzodiazepines, breathing retraining, brief dynamic psychotherapy, buspirone, client-centred therapy, cognitive behavioural therapy (CBT) (alone or plus drug treatments), cognitive restructuring, couple therapy, exposure (external or interoceptive), insight-orientated therapy, monoamine oxidase inhibitors (MAOIs), psychoeducation, selective serotonin reuptake inhibitors (SSRIs), self-help, and tricyclic antidepressants (imipramine).

What is the usual length of stay in a psychiatric ward?

INTRODUCTION: Admission statistics can provide valuable data for planning and policy in the NHS. However, there has been little agreement about meaningful ways of summarising and expressing such data. We set out to (i) explore the distribution of length of inpatient stay and to examine the most appropriate measure of central tendency; and (ii) examine the relationship between severity of mental illness and length of stay. METHOD: Length of stay was recorded for a 12-month cohort of psychiatric admissions to a district general hospital psychiatric unit. These data were compared with a previous cohort study and also with DoH statistics. RESULTS: Length of inpatient stay followed an exponential decay curve. The median length of stay for all three cohorts examined was approximately 15 days. Absence of serious mental illness was significantly associated with shorter length of stay. CONCLUSION: Length of stay is not normally distributed and so the median value is the preferred measure of central tendency. All cohorts examined showed a median value of around 15 days. Large numbers of patients are admitted for a week or less which has implications for inpatient and community services. Qnt] Psych Clin Pract 2004; 8: 53-56).